Search

Background: There are few published studies with very long-term follow-up of combined intra- and extra-articular anterior cruciate ligament (ACL) reconstruction. Purpose: To analyze clinical and radiographic outcomes of over-the-top ACL reconstruction plus extra-articular lateral tenodesis with autologous hamstrings at minimum 20-year follow-up. Study Design: Case series; Level of evidence, 4. Methods: Of 60 originally eligible patients who underwent over-the-top ACL reconstruction with double-stranded hamstring tendon (leaving intact graft tibial insertions) and extra-articular lateral plasty (performed with the remnant part of tendons), 52 were prospectively evaluated at a minimum 20-year follow-up (mean follow-up, 24 years; 41 men, 11 women; mean age at time of surgery, 25.5 ± 7.6 years). Twenty-nine patients were available for prospective evaluations: clinical (Lysholm, Tegner, and objective International Knee Documentation Committee [IKDC]), instrumented (KT-2000), and radiographic (standard, long-standing, and Merchant views). Subjective KOOS (Knee injury and Osteoarthritis Outcome Score) and objective inertial sensor pivot-shift analysis (KiRA) were carried out at final follow-up. Twenty-three patients were investigated by phone interview for subjective Tegner score and documented complications, rerupture, or revision surgery. Results: At final follow-up, mean Lysholm score was 85.7 ± 14.6; median Tegner score, 4 (range, 3-5); sport activity resumption, 86.2%; and objective IKDC score, good or excellent in 86% of patients (31%, A; 55%, B). Only 3 of 26 patients (12%) had >5-mm manual maximum KT-2000 side-to-side difference. KiRA system documented positive pivot-shift (>0.9-m/s2 tibial acceleration side-to-side difference) in these 3 of 26 patients (12%). Statistically significant changes were as follows: decrease in Tegner score from 7 (range, 6-8) at 5-year follow-up to 4 (range, 3-5) at 10 years (P < .0001) and decrease in Lysholm score from 96.1 ± 7.3 at 10-year follow-up to 85.7 ± 14.6 at 20 years (P = .0003). Radiographic evaluation demonstrated significant difference of medial joint space between injured and healthy knees in patients with concomitant medial meniscectomy (n = 8, 3.2 ± 0.6 vs 5.0 ± 1.8 mm, P = .0114). No significant differences were reported regarding lateral or patellofemoral joint space. One patient (2%) experienced rerupture, with 3 of 52 (5.8%) having a contralateral ACL injury (excluded from KT-2000 and radiographic evaluations). Overall, 4 of 29 clinical failures (objective IKDC, KT-2000) and 1 rerupture among 52 patients were registered at final follow-up. Conclusion: Studied surgical technique demonstrated good results in laxity control at 20-year minimum follow-up. The lateral extra-articular plasty associated with ACL reconstruction did not generate lateral knee or patellofemoral osteoarthritis. The factor increasing osteoarthritis was meniscectomy. [ABSTRACT FROM AUTHOR]

A variety of graft sources have been used for ACL reconstruction to improve functions and kinematics in ACL deficient knees. The two most commonly used autogenous grafts are the central third of the patellar tendon and the hamstring tendon constructs. The choice of different grafts and different construct influence the final clinical outcome of ACL reconstruction. The 3 groups, of 25 patients each, were generated by choosing the technique (PT tendon, 4 strand hamstring, and single hamstring plus extraarticular plasty) to utilize and followed for 5 years, with an alternate systematic sampling. Our comparison has shown significant kneeling pain in the patellar tendon with respect to the groups with hamstrings techniques. Single hamstring plus extraarticular plasty achieved subjective score significantly higher with respect to the other two groups as well as for the time to resume sport. The study confirms that patellar tendon and hamstring can be equivalent options for ACL reconstruction. This study demonstrated that a superior outcome as far as subjective clinical findings were concerned, was obtained in group III. Patients in the latter group were also able to return to sports sooner than those in the bone-patellar tendon graft group and the four-strand hamstring group. [ABSTRACT FROM AUTHOR]

Purpose: Meniscal repairs are the most common associated procedures during ACL reconstruction, but they present challenging indications and possible risks of complications or failures. The aim of the present study is to assess the clinical outcomes of all-inside meniscal repairs in the setting of ACL reconstruction.Methods: Twenty patients with ACL reconstruction and all-inside meniscal repair were compared to 20 patients with isolated ACL reconstruction. All patients were prospectively evaluated pre-operatively, at four month, and 18-month follow-up with KT-1000, Kira accelerometer for pivot-shift, KOOS, Marx score, and SF-36. Meniscal healing and presence of peri-meniscal cysts were assessed on standardized 1.5-T MRIs performed at 18 months.Results: Twenty-one meniscal repairs were performed in 20 patients (81% medial, 19% lateral). At 18 months, 48% had complete healing, 38% had incomplete healing, and 14% had no healing. Peri-meniscal cysts were present in 33% of cases. Worst pre-operative KOOS pain (p = 0.0435) and ADL (p = 0 .0201) were present in patients with meniscal lesion, while no differences were present at four months and 18 months between patients with or without meniscal repair (p > 0.05). No significant differences were noted stratifying patients according to meniscal healing or cyst presence, except of a lower Qol KOOS subscale in patients with peri-meniscal cysts (p = 0.0430).Conclusions: Meniscal repairs produced good short-term results when performed in combination to ACL reconstruction. Full or partial healing at MRI was present in 86% of cases. One patient out of three developed peri-meniscal cysts. [ABSTRACT FROM AUTHOR]

Background: Long-term patient-reported outcome measures (PROMs) and predictors of success or failure after anterior cruciate ligament (ACL) reconstruction are not fully understood, especially when combined with a lateral extra-articular reconstruction. Purpose: To assess the long-term PROMs, revision rate, and predictors of success or failure after ACL reconstructions using an over-the-top surgical technique with single-bundle hamstring tendon autografts and a lateral extra-articular reconstruction. Study Design: Case series; Level of evidence, 4. Methods: The study cohort consisted of 267 consecutive patients (mean age, 30.7 years) who underwent ACL reconstruction with an over-the-top surgical technique with single-bundle hamstring tendon autografts and a lateral extra-articular augmentation between November 2007 and May 2009. The number of subsequent ACL revisions and reoperations were recorded. Subjective clinical status was assessed with PROMs—specifically, the Knee injury and Osteoarthritis Outcome Score (KOOS), Lysholm, Tegner, and visual analog scale for pain—at a minimum follow-up of 10 years. Results: Overall, 3% of patients underwent ACL revision, with a 10-year survival rate of 96.3%. High sport activity (hazard ratio, 6.9; P =.285) and concomitant meniscal lesion (hazard ratio, 2.6; P =.0487) were predictors of ACL revision or new meniscectomy. The mean ± SD Lysholm score was 94.1 ± 10.8, while that for the visual analog scale for pain was 0.2 ± 0.9 at rest and 2.1 ± 2.6 during activity. KOOS subscale scores were as follows: 95.7 ± 8.1 for Pain, 92.5 ± 10.5 for Symptoms, 98.4 ± 7.4 for Activities of Daily Living, 90.7 ± 17.2 for Sport, and 91.2 ± 17.1 for Quality of Life; respectively, 88%, 99%, 81%, 89%, and 91% of patients achieved the Patient Acceptable Symptom State. Female sex and chondropathy with Outerbridge grade ≥2 were predictors of worse KOOS subscales. Overall, 82% of patients returned to sport, and 57% were still participating at the 10-year evaluation. Conclusion: ACL reconstruction with an over-the-top surgical technique with single-bundle hamstring autografts and a lateral extra-articular reconstruction provided satisfactory results in terms of function, symptoms, sports, and quality of life in 80% to 90% of patients after 10 years. Long-term survivorship was 96%. Sport participation declined from 82% postoperatively to 57% at long-term follow-up. A concomitant medial meniscal lesion was a predictor of higher risk of ACL failure or new meniscal lesion, while advanced chondropathy and female sex were predictors of higher pain, lower function, and poor quality of life scores. [ABSTRACT FROM AUTHOR]

Background: Arthroscopic debridement with graft preservation has been advocated as the treatment of choice for septic arthritis after anterior cruciate ligament (ACL) reconstruction, but no previous studies have investigated if hardware removal, while retaining the graft in situ, improves the success rate. Moreover, it is unclear whether the premature removal of fixation devices may affect graft integration and knee stability. Purpose/Hypothesis: The purpose was to assess the clinical and functional outcomes of patients with septic arthritis after ACL reconstruction who underwent arthroscopic debridement, while retaining the graft in situ but removing fixation devices, and to determine if premature hardware removal affects graft integrity and function. The hypothesis was that arthroscopic debridement with hardware removal would be effective in eradicating infections while not compromising graft integration and function. Study Design: Case series; Level of evidence, 4. Methods: From a cohort of 2384 cases of arthroscopic ACL reconstruction, 24 patients with postoperative septic arthritis were included for the analysis; 18 patients were available for a clinical evaluation using the International Knee Documentation Committee (IKDC) form, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Lysholm score, and Tegner score at a minimum 12-month follow-up. Knee laxity was assessed clinically with standardized manual laxity tests and instrumentally using an arthrometer and a triaxial accelerometer. Additionally, 3-T magnetic resonance imaging (MRI) at final follow-up was performed, focusing on the graft signal, the cartilage status, and the occurrence of arthrofibrosis. Results: Eradication of the infection was achieved in all cases, and only 1 graft removal was performed because of insufficient tension. Among the remaining 23 patients, a single arthroscopic debridement procedure with hardware removal while preserving the graft was effective in 21 cases (91%) at a mean of 30 ± 37 days from ACL reconstruction to debridement. At last follow-up, 2 patients required a further ACL revision procedure. The mean IKDC, WOMAC, Lysholm, and Tegner scores of the patients available for the clinical evaluation were 75 ± 19, 90 ± 8, 79 ± 21, and 6 ± 2, respectively. No abnormal laxity was reported on manual testing, and arthrometric and accelerometer tests also demonstrated good knee stability (mean KT-1000 arthrometer side-to-side difference was 1.6 ± 1.2 mm at manual maximum force). On MRI, a good graft signal was found in 50% of cases, while concomitant signs of arthrofibrosis were detected in 81% of patients. Severe cartilage defects (International Cartilage Repair Society grade ≥3) were reported in 63% of cases. Conclusion: Arthroscopic debridement with hardware removal was effective in the eradication of infections after ACL reconstruction with extra-articular fixation while preserving graft integrity without compromising knee stability. Patients and surgeons should be aware of complications that might affect the outcome, particularly arthrofibrosis and chondrolysis. [ABSTRACT FROM AUTHOR]

Purpose: To assess the rate of return to sport (RTS) following revision Anterior Cruciate Ligament Reconstruction (ACLR) in a rehabilitation-based cohort of patients. A secondary goal of the study was to evaluate the association between compliance in post-operative rehabilitation and RTS rate.Methods: The study cohort included 79 sport-active patients (62 males, 17 females, 30.0 ± 10.2 years old) who underwent revision ACLR surgery and followed the same functional-oriented rehabilitation protocol. Patients were evaluated using a RTS survey: return to any kind of sport participation, return to the same pre-injury sport, return to the same sport at the same pre-injury level. With regards to compliance in post-operative rehabilitation, patients were then grouped in (1) Fully Compliant (FC), (2) Moderately Compliant (MC), (3) Scarcely Compliant (SC), and (4) Non-Compliant (NC).Results: At an average follow-up of 29 ± 12 months, 86% of the patients returned to some kind of sport activity, 62% returned to the same pre-injury sport activity and 59% returned to the same pre-injury level of sport activity. While no surgical aspects were correlated with RTS, higher BMI was found to have a negative influence (p = 0.033). Regardless of the type of sport, compliance significantly affected RTS at the same pre-injury level (p = 0.006): 86% in FC, 67% in MC, 50% in SC, and 45% in NC. For each compliance goal achieved, the probability of RTS increased by 68% (OR = 1.68; p = 0.027).Conclusion: RTS at the same pre-injury level after revision ACLR is challenging. A higher compliance in rehabilitation significantly increases the chances of RTS.Level Of Evidence: IV. [ABSTRACT FROM AUTHOR]

Background: Failure of anterior cruciate ligament (ACL) reconstruction or an injury to the ACL in the contralateral knee represents a devastating event for patients, especially those young and physically active. However, controversies are still present regarding long-term failure rates and risk factors. Purpose: To assess the long-term rate of ipsilateral graft failure and contralateral ACL injuries after ACL reconstruction performed at a single center using the same surgical technique with a hamstring autograft and to investigate the effect of sex, age, and preinjury activity level as predictors of second ACL injuries. Study Design: Case series; Level of evidence, 4. Methods: The study cohort consisted of 244 consecutive patients (mean age, 30.7 years) who underwent ACL reconstruction with a single bundle plus lateral plasty technique using the hamstring tendon between November 2007 and May 2009. The number of subsequent ACL injuries (ipsilateral ACL revision or contralateral ACL reconstruction) was determined at a minimum follow-up of 10 years. Survivorship of either knee and subgroup analysis included sex, age, preoperative Tegner activity level, timing of ACL reconstruction, body mass index, and smoking status. Results: Ipsilateral ACL revision was performed in 8 (3.4%) patients and contralateral ACL reconstruction in 19 (7.8%) patients. Only 1 patient had both ipsilateral and contralateral injuries. No predictors were found for ipsilateral ACL revision, while age <18 years and preoperative Tegner level ≥7 had a higher risk of contralateral ACL reconstruction. The highest rate of a second ACL reconstruction procedure was in young (<18 years) and active (Tegner ≥7) patients, in whom the 10-year survival of either knee was 61.1%. Six years after primary ACL reconstruction, the rate of contralateral ACL reconstruction was significantly higher than that of ipsilateral ACL revision (hazard ratio, 2.4-3.6). Conclusion: In the long term, a second injury to either the ipsilateral or the contralateral knee in young and active populations could reach 40%, with a more than double-fold risk of contralateral ACL reconstruction compared with ipsilateral ACL revision. [ABSTRACT FROM AUTHOR]

Purpose: The aim of this study was to follow up, clinically and radiographically, skeletally immature patients who underwent ACL reconstruction with an all-epiphyseal "over-the-top" technique.Methods: Twenty athletes aged between 8 and 13 years were enrolled and retrospectively evaluated. The subjects underwent surgical ACL reconstruction between 2009 and 2013. The surgical technique consisted of a single-bundle all-epiphyseal ACL reconstruction with an extra-articular lateral tenodesis. The mean follow-up was 54 months [34-123] after surgery. Clinically, the patients were evaluated pre- and post-operatively with Lysholm and KOOS scores; sport activity level was evaluated using the pre-injury, pre-operative and post-operative Tegner scores. Objective IKDC was calculated post-operatively. The joint laxity was evaluated by KT1000 and Rolimeter arthrometers. Panoramic AP standing radiographs of the lower limbs and lateral knee radiographs were also taken at the follow-up to evaluate limb length discrepancies (LLD) and axial malalignment. Normally distributed parameters were presented as mean ± standard deviation, while the non-normally distributed parameters were presented as median [25° percentile, 75° percentile].Results: Clinical scores showed significant (P < 0.01) improvement: Lysholm and KOOS scores improved from 40 [22; 65] and 59 [42, 73], respectively, to 100 [95; 100] and 99 [97;100] after surgery. Tegner score improved from 2 [2; 2] pre-operatively to 7 [3; 9] at follow-up (P < 0.01). At follow-up, IKDC score was A for 19 patients and one who scored B. All patients returned to sport activity and had good stability at follow-up: the KT1000 showed a median side-to-side difference of 0.0 mm [- 0.4; 1.0] for the standard force evaluation and 0.0 mm [- 1.0; 0.8] for manual-maximum test. The Rolimeter showed median side-to-site difference of 0.0 mm [- 1.0; 0.8]. Three minor leg length discrepancies and axial deviations were observed at the radiograph: one patient had 0.6 cm lengthening and 4° of varus, one had 1 cm lengthening, and one had 3° of varus (in comparison with the non-operated limb). No re-injury was observed.Conclusion: This study demonstrates that the modified all-epiphyseal single-bundle "over-the-top" technique is a viable and safe option for ACL reconstruction in pediatric subjects. These results support once more that not only ACL reconstruction is a safe procedure in skeletally immature patients, but also it is highly recommended for those who want to pursue an active and sportive life.Level Of Evidence: Case series, IV. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of the current prospective study was to assess the changes over time in patients tested at 6 months and 9 months after anterior cruciate ligament reconstruction (ACLR) with a return to sport (RTS) test battery. It was hypothesized that more patients passed RTS criteria at 9 months compared to 6 months.Methods: Sixty-two ACLR patients performed a test battery at an average of 6.5 ± 0.7 and 9.5 ± 0.9 months after ACLR. All patients underwent a standardized rehabilitation protocol. The test battery consisted of the following tests: a jump-landing task assessed with the Landing Error Scoring System (LESS), three single-leg hop tasks (single-leg hop test, triple-leg hop test, side hop test), isokinetic quadriceps and hamstring strength at 60, 180 and 300°/s and two questionnaires (IKDC and ACL-RSI). Cut off criteria were set as Limb Symmetry Index (LSI) > 90% (for isokinetic strength and for single-leg hop tasks), LESS < 5, IKDC score within 15th percentage of healthy subjects and ACL-RSI > 56 respectively.Results: At 6 months, two patients (3.2%) passed all criteria. At 9 months, seven patients (11.3%) passed all criteria. Patients improved in all RTS criteria over time except for the IKDC score. Twenty-nine patients (46.8%) did not pass the strength criterion at 60°/s at 9 months after ACLR.Conclusions: The percentages of patients passing all RTS criteria were low at both 6 and 9 months after ACLR. Quadriceps strength revealed persistent deficits and the lack of improvement in the IKDC score questionnaires shows insufficient self-reported knee function for RTS.Level Of Evidence: III. [ABSTRACT FROM AUTHOR]

Purpose: The main goal of this work was to evaluate the pivot shift test in awake and anesthetized patients by using two different quantitative methodologies and comparing the results with the standard clinical grading, taking advantage of a multicenter international study.Methods: Patients between 16 and 50 years of age undergoing primary unilateral single-bundle anterior cruciate ligament (ACL) reconstruction were considered eligible. The pivot shift test was performed pre-operatively, with the patient awake and again with the patient under general anaesthesia. The pivot shift test was clinically graded as defined by the International Knee Documentation Committee. The instrumented assessment was performed by using two non-invasive acquisition systems; specifically, a system exploiting an inertial sensor and a video-based application developed on a commercial tablet using skin markers. Lateral compartment translation and the tibial acceleration reached during joint reduction were used as quantitative parameters.Results: A total of 103 patients were enrolled in the study. Statistically significant difference was found between the distributions of clinical grade evaluated in awake patients and those under general anaesthesia (P < 0.01). Comparing awake patients to those under general anaesthesia, lower values were found both for tibial acceleration (3.7 ± 1.5 vs 6.0 ± 4.6 m/s2, P < 0.01) and lateral compartment translation of the involved limb (2.2 ± 1.7 vs 3.0 ± 2.2 mm, P < 0.01).Conclusions: This study indicated that significant differences in the grading of the pivot shift test exist between awake and anesthetized patients, regardless of the use of quantitative instruments during the evaluation. Actual clinical assessment reported indeed its weakness, presenting subjective variability and dependence on tester's experience. However, several factors might influence the validity of awake examination such as experience level of examiner and cultural factors, as seen in this international multicenter study.Level Of Evidence: Prospective comparative study, Level II. [ABSTRACT FROM AUTHOR]

Purpose: To compare the clinical, objective and radiographic long-term results of patients with anterior cruciate ligament (ACL) lesion and partial medial meniscus defects, treated with ACL reconstruction and partial medial meniscectomy or medial CMI implant.Methods: Seventeen patients treated with combined ACL reconstruction and medial CMI and 17 patients treated with ACL reconstruction and partial medial meniscectomy were evaluated with mean follow-up 9.6 years with Lysholm, Tegner, objective and subjective International Knee Documentation Committee scores, and VAS for pain. Arthrometric evaluation was performed with KT 2000. Weigh-bearing radiographs, antero-posterior and Rosenberg view, were also performed and evaluated with Kellgren-Lawrence score, Ahlback score and joint space narrowing.Results: Pre-operative demographic parameters and clinical scores between patients treated with CMI and partial medial meniscectomy revealed no significant differences. A significant improvement of all the clinical scores was detected in both groups from pre-operative status to final follow-up. No significant difference between groups were found for clinical and radiographic scores; however, the chronic subgroup of patients treated with CMI showed a significantly lower level of post-operative knee pain compared to patients treated with partial medial meniscectomy and the acute subgroup of medial CMI showed better arthrometric scores.Conclusion: Good long-term clinical results in terms of stability, subjective outcomes and objective evaluation were reported both for medial CMI implant and partial medial meniscectomy, combined with ACL reconstruction for the treatment of partial medial meniscus tears combined with ACL lesions. Chronic meniscal tears treated with medial CMI reported lower levels of post-operative pain compared to meniscectomy, while acute lesions treated with medial CMI showed less knee laxity. Therefore, the use of the collagen meniscus implant in the case of anterior knee instability with a meniscal defect appears justified and able to improve clinical outcomes in the long term.Level Of Evidence: Retrospective comparative study, Level III. [ABSTRACT FROM AUTHOR]

Purpose: A deficiency of posterolateral structures significantly increases the varus load on the ACL, while a chronic ACL lesion, the increased tibial rotation and the repetitive non-physiological knee motion, could affect and damage the integrity of the popliteus tendon. Therefore, the aim of the present study was to report the very long clinical outcomes of a combined single-bundle BPTB ACL reconstruction and popliteus plasty according to Bousquets technique, for the treatment of combined chronic anterior and posterolateral laxities.Methods: Fifteen patients that underwent combined ACL reconstruction and popliteal plasty according to Bousquets technique were available at mean 26.8 ± 1.0 years (range 25.4-28.0 years). All the patients were evaluated clinically and 13 by means of KT-1000 Arthrometer as well. Subjective evaluation was performed with the subjective IKDC, WOMAC and a 0-10 VAS for pain scales.Results: At clinical evaluation, 10 patients (67 %) presented a negative anterior drawer test; Lachman test was negative in nine patients (60 %); the varus stress test was negative in eight (53 %); and the dial test was negative in all but one patient (93 %). Only two patients (15 %) presented a side-to-side difference >5 mm at the instrumented laxity evaluation.Conclusion: The combined single-bundle BPTB ACL reconstruction and popliteal plasty according to Bousquets technique were able to produce very good long-term results, in terms of knee stability, subjective outcomes, functional results and return to sport activity, in case of chronic anterior and posterolateral laxities.Level Of Evidence: Retrospective case series, Level IV. [ABSTRACT FROM AUTHOR]